Pre-operative rehabilitation in lower-limb amputation patients and its effect on post-operative outcomes

Predicting Prosthetic Mobility at Discharge From Rehabilitation Following Major Amputation in Vascular Surgery

OBJECTIVE

This study aimed to construct a decision aid to estimate the likelihood of independence with a prosthesis following rehabilitation for limb loss secondary to advanced ischaemia (acute or chronic limb threatening ischaemia) or diabetic foot disease (DFD). A secondary aim was to determine whether prosthetic independence is a surrogate marker of long term survival.

METHODS

A retrospective cohort study of a prospectively maintained database of unilateral amputations due to ischaemia or DFD entering rehabilitation between 2007 and 2020 was performed. Predictors of independent prosthetic mobility (IPM) were used in construction of the IPM prediction model, which underwent bootstrap internal and criterion validation through correlation with predictors of other measures of function: Timed Up and Go (TUG) and two minute walk test. Kaplan-Meier and Cox regression analyses were performed to address the secondary aim.

RESULTS

Of the 771 patients included, only 49.9% of amputees achieved IPM. Independent negative predictors of IPM were age > 75 years, female sex, higher amputation level, active malignancy, cerebrovascular disease, end stage renal disease, and cognitive impairment. The model yielded high discrimination (C statistic 0.778), and internal validation was demonstrated with bootstrapping (C statistic 0.778), confirming no over optimism. There was a strong correlation between IPM, TUG, and two minute distance and their predictors, confirming strong criterion validity. The IPM group had a median survival of 93.7 (80.7, 105) months, whereas the non-IPM group fared worse with a median survival of 56.6 (48.5, 66.7) months (p < .001).

CONCLUSION

An internally validated decision aid for estimating the likelihood of independence with a prosthesis after major amputation was constructed. A strong association between female sex and poorer prosthetic mobility was observed. Prosthetic function was shown to be a surrogate marker of long term survival. Future research will involve external validation studies to confirm the generalisability of the decision aid in clinical practice.

Management and rehabilitation of moderate-to-severe diabetic foot infection: a narrative review

Diabetic foot is one of the most devastating consequences of diabetes, resulting in amputation and possibly death. Therefore, early detection and vigorous treatment of infections in patients with diabetic foot are critical. This review seeks to provide guidelines for the therapy and rehabilitation of patients with moderate-to-severe diabetic foot. If a diabetic foot infection is suspected, bacterial cultures should be initially obtained. Numerous imaging studies can be used to identify diabetic foot, and recent research has shown that white blood cell single-photon emission computed tomography/computed tomography has comparable diagnostic specificity and sensitivity to magnetic resonance imaging. Surgery is performed when a diabetic foot ulcer is deep and is accompanied by bone and soft tissue infections. Patients should be taught preoperative rehabilitation before undergoing stressful surgery. During surgical procedures, it is critical to remove all necrotic tissue and drain the inflammatory area. It is critical to treat wounds with suitable dressings after surgery. Wet dressings promote the formation of granulation tissues and new blood vessels. Walking should begin as soon as the patient's general condition allows it, regardless of the wound status or prior walking capacity. Adequate treatment of comorbidities, including hypertension and dyslipidemia, and smoking cessation are necessary. Additionally, broad-spectrum antibiotics are required to treat diabetic foot infections.

Effect of concurrent training in unilateral transtibial amputees using Paralympic athletes as a control group

CONTEXT

Transtibial Amputation (TA) predisposes to a sedentary lifestyle.

OBJECTIVES

To evaluate the efficiency of a short-term (8-week) Concurrent Training (CT) program in Unilateral Transtibial Amputees (UTA) and to compare it with the physical condition of a group of Paralympic athletes in preparation for the Rio de Janeiro Paralympics.

DESIGN

This was a longitudinal, prospective and controlled trial study.

METHODS

Thirty-four male subjects with UTA and using prostheses for six months or more were selected for this study. They were divided into two groups: Group 1 (G1) ‒ 17 non-athlete and untrained UTA and Group 2 (G2) ‒ 17 paralympic athletes with active UTA in the training phase. G1 was evaluated before and after eight weeks of CT and G2 made a single evaluation for control. All were submitted to anamnesis, clinical evaluation (blood pressure, electrocardiogram, and heart rate) and cardiopulmonary exercise testing on a lower limb cycle ergometer, and isokinetic knee dynamometry. The CT of G1 included resistance exercise and aerobic interval training on a stationary bicycle and G2 followed the training of the Paralympic teams.

RESULTS

Patients were retested by the same methods after CT. The two most important central dependent variables (maximal oxygen uptake and muscular strength) increased by 22% and knee extensor and flexor strength by 106% and 97%, respectively.

CONCLUSION

After eight weeks of CT, there was an improvement in general functional condition, muscle strength, and cardiorespiratory performance improving protection against chronic diseases and quality of life.

Socioecological model-based design and implementation principles of lower limb preservation programs as partners for limb-loss rehabilitation programs- A mini-review

People with lower limb loss, especially of dysvascular etiology, are at substantial risk for both ipsilateral and contralateral reamputation. Additionally, while not as well documented for reamputation, there is recognition that amputation incidence is influenced by not only sociodemographic factors such as sex, race, socioeconomic status, but also by system factors such as service access. A systems strategy to address this disparity within the field of limb-loss rehabilitation is for Limb-loss Rehabilitation Programs (LRP) to partner with medical specialists, mental health professionals, and Limb Preservation Programs (LPP) to provide comprehensive limb care. While LPPs exist around the nation, design principles for such programs and their partnership role with LRPs are not well established. Using a socioecological model to incorporate hierarchical stakeholder perspectives inherent in the multidisciplinary field of limb care, this review synthesizes the latest evidence to focus on LPP design and implementation principles that can help policymakers, healthcare organizations and limb-loss rehabilitation and limb-preservation professionals to develop, implement, and sustain robust LPP programs in partnership with LRPs.

Impact of Kinesiotherapy and Hydrokinetic Therapy on the Rehabilitation of Balance, Gait and Functional Capacity in Patients with Lower Limb Amputation: A Pilot Study

The purpose of this pilot study was to identify impact differences in the rehabilitation of balance, gait and functional capacity in patients with lower limb amputation performing hydrokinetic therapy and kinesiotherapy programs during the pre-prosthetic and prosthetic phases. The study included 16 male patients aged 40–60 years with amputated lower limbs for 6 to 12 months, which involved transfemoral amputation (TFA), transtibial amputation (TTA), traumatic and vascular amputation, who were divided into the following two groups: the hydrokinetic therapy (HKT) group and the kinesiotherapy (KT) group, named after the content of the rehabilitation programs that were implemented for 2 weeks in the pre-prosthetic and prosthetic periods. The initial and final evaluation of the participants included the following tests: the Berg Scale and the four square test for the evaluation of the balance; the PodoSmart device for gait assessment; through the walking test over 6 min, we evaluated the functional capacity. The results were processed in SPSS 24. Analysis of the results on balance rehabilitation through the Berg Scale highlighted that the progress related to the mean of the total score was 7.62 points, p = 0.00 for the HKT group and 7.50 points, p = 0.00 for the KT group, while in the four square step test, the mean of progress was 6.125 s, p = 0.00 for the HKT group and 6 s, p = 0.000 for the KT group. The PodoSmart gait analysis revealed that the HKT group showed a progress mean of 4.875%, p = 0.00, for the foot symmetry parameter, which was 1.875% less than the score achieved by the KT group whose symmetry progress mean was 6.75%, p = 0.00, while the average progress mean for the cadence parameter was 2.75 steps/min higher for the KT group than the HKT group. The comparative analysis of the impact of these two programs on the patients’ functional capacity indicated that the score recorded by the KT group was a progress mean of 15.12 m, p = 0.00 better than the HKT group for the travelled distance parameter; the implementation of the hydrokinetic therapy program led to better exercise adaptation for the HKT group compared to the KT group at an average HR (HRavg) with 0.50 BPM, p = 0.00. After analyzing the results, it has been found that hydrokinetic therapy programs have a greater impact on balance rehabilitation and exercise adaptation, while kinesiotherapy programs have a greater impact on gait rehabilitation and functional capacity optimization for the travelled distance parameter.

Prehabilitation-plus for patients undergoing major lower limb amputation may reduce acute hospital and total hospital length of stay: a retrospective, matched, case-controlled pilot service evaluation

Background/Aims

‘Prehabilitation’ refers to interventions that seek to enhance a person's functional capacity to help withstand a forthcoming stressor, such as major surgery. There is little research evaluating prehabilitation before major lower limb amputation. This study evaluated if a comprehensive multidisciplinary pre-admission programme, which included prehabilitation plus other interventions (eg education, home assessment and modifications), hereinafter called ‘prehabilitation-plus’, might shorten hospital length of stay by allowing earlier discharge home from hospital after major lower limb amputation. The aim of this study was to investigate the effect of prehabilitation-plus on hospital length of stay and discharge destination for patients undergoing major lower limb amputation.

Methods

Seven patients receiving prehabilitation-plus were retrospectively matched with seven control patients in this case-controlled pilot service evaluation. Prehabilitation-plus was provided by a multidisciplinary team. Hospital length of stay was compared using Mann–Whitney U tests and discharge destination using Fisher's exact test.

Results

Acute hospital and total hospital length of stay were significantly lower in the prehabilitation-plus group than the control group (P=0.038 and 0.011 respectively). No significant difference was seen for rehabilitation hospital length of stay (P=0.400). More prehabilitation-plus patients were discharged directly home after their acute hospital stay, but this was not significant (P=0.286).

Conclusions

Patients who received prehabilitation-plus had reduced acute hospital and total hospital length of stay compared to matched control patients. While these preliminary results are promising for the ability of programmes such as prehabilitation-plus to reduce hospital length of stay, further studies with more robust designs are required to confirm and extend this finding.